Factors associated with compliance of alcoholics in outpatient treatment

Personality traits and alcohol consumption: Secondary analysis of the Self-Match Study

Background

This secondary analysis of the Self‐Match Study explores whether personality traits affect the treatment outcome for alcohol use disorders (AUD). We designed the Self‐Match Study to investigate whether clients choosing between treatment options improves treatment outcomes. The primary outcome report revealed no difference in the outcome, whether treatment allocation was based on clinician matching or self‐matching. Because willingness to choose, choice of treatment method, and compliance with treatment may be related to personality, this exploratory sub‐study investigated the influence of personality traits on treatment outcome.

Method

We enrolled 402 consecutive clients (female 46.7%, mean age 47.4) seeking treatment at the outpatient alcohol treatment center in Odense, Denmark. Clients were randomized to treatment by expert‐match or self‐matching. Data on alcohol consumption (Timeline Follow Back), personality traits (NEO‐FFI‐3), and retention in care were collected at baseline and 6‐month follow‐up. Outcomes were compliance, sensible drinking (alcohol intake below National Recommendations), and the number of heavy drinking days at follow‐up.

Results

A high neuroticism score was negatively associated with treatment completion. Further, clients with a high score on neuroticism, openness, and extraversion, or a low score on conscientiousness were less likely to reduce their drinking to a sensible level at follow‐up. We also found that low scores on conscientiousness were associated with having more heavy drinking days at follow‐up. The personality traits neuroticism and openness were associated with treatment preferences.

Conclusions

Personality traits influence 6 months drinking outcomes for people receiving AUD treatment.

Personality traits seem to not affect treatment completion. However, a high score on neuroticism, openness, extraversion, or a low score on conscientiousness influence the drinking pattern in different ways at 6‐month follow‐up. The personality traits neuroticism and openness were associated with preferences for specific treatment methods, but further research is needed on this matter. Tentative conclusions are that client‐centered treatment is preferable and shared decision‐making should be considered as part of the treatment regimen.

BLEND-A: blending internet treatment into conventional face-to-face treatment for alcohol use disorder - a study protocol

BACKGROUND

A major challenge to psychological treatment for alcohol use disorder (AUD) is patient non-compliance. A promising new treatment approach that is hypothesized to increase patient compliance is blended treatment, consisting of face-to-face contact with a therapist combined with modules delivered over the internet within the same protocol. While this treatment concept has been developed and proven effective for a variety of mental disorders, it has not yet been examined for AUD.

AIMS

The study described in this protocol aims to examine and evaluate patient compliance with blended AUD treatment as well as the clinical and cost effectiveness of such treatment compared to face-to-face treatment only.

METHODS

The study design is a pragmatic, stepped-wedge cluster randomized controlled trial. The included outpatient institutions (planned number of patients: n = 1800) will be randomized in clusters to implement either blended AUD treatment or face-to-face treatment only, i.e. treatment as usual (TAU). Both treatment approaches consist of motivational interviewing and cognitive behavioral therapy. Data on sociodemographics, treatment (e.g. intensity, duration), type of treatment conclusion (compliance vs. dropout), alcohol consumption, addiction severity, consequences of drinking, and quality of life, will be collected at treatment entry, at treatment conclusion, and 6 months after treatment conclusion. The primary outcome is compliance at treatment conclusion, and the secondary outcomes include alcohol consumption and quality of life at six-months follow-up. Data will be analyzed with an Intention-to-treat approach by means of generalized linear mixed models with a random effect for cluster and fixed effect for each step. Also, analyses evaluating cost-effectiveness will be conducted.

DISCUSSION

Blended treatment may increase treatment compliance and thus improve treatment outcomes due to increased flexibility of the treatment course. Since this study is conducted within an implementation framework it can easily be scaled up, and when successful, blended treatment has the potential to become an alternative offer in many outpatient clinics nationwide and internationally.

TRIAL REGISTRATION

Clinicaltrials.gov .: NCT04535258 , retrospectively registered 01.09.20.

The effect of exercise as adjunctive treatment on quality of life for individuals with alcohol use disorders: a randomized controlled trial

Background

A physically active lifestyle contributes to the prevention of lifestyle diseases, promotion of physical health, and reduction of pain, among other benefits. Being physically active also promotes mental health for many individuals, in the form of improved mood, increased self-efficacy and reduced risk of depression. Alcohol-dependent individuals may experience a better quality of life when supplementing their treatment with physical exercise. This study aimed to evaluate the effect of exercise on Quality of Life among patients with alcohol use disorder in a large randomized controlled trial.

Methods

The study had three arms: Patients were allocated to (A) treatment as usual, (B) treatment as usual and supervised group exercise two days a week of one hour each, (C) treatment as usual and individual physical exercise minimum two days a week. Duration of the intervention was six months. Data on values of Quality of Life were collected at baseline (before treatment start and at time of enrollment in the study), and at follow-up (at six months after enrollment in the study) using the EQ-5D questionnaire and the EQ-VAS. The sample consisted of 117 consecutive patients, and the follow-up rate was 66.6%. Intention-to-treat analyses were conducted to evaluate the effect of exercise on quality of life.

Results

Although not statistically significant, a substantial portion of the participants in the individual exercise condition reported that they had no pain or discomfort (one of the five quality of life dimensions measured by EQ-5D questionnaire) compared to the controls at follow-up. No difference was found between the groups regarding the EQ-VAS.

Conclusion

The exercise intervention had no effect on quality of life for patients with alcohol use disorder, nor was quality of life improved across the total sample. More research in how to improve quality of life for patients with alcohol use disorder is needed.

Trial registration

ISRCTN74889852 (retrospectively registered, date: 16/05/2013).

Is treatment outcome improved if patients match themselves to treatment options? Study protocol for a randomized controlled trial

BACKGROUND

Research on matching patients to treatment has shown that matching grounded in expert views is little better than allocating patients by chance. Furthermore, there is growing emphasis on involving patients in their own treatment as a key to health behavior change. Research on the benefit of having patients choose their treatment from among options, in contrast to being assigned to a treatment by experts, has been limited. Consequently, we designed a rigorous test of patient self-matching to determine whether it does improve retention, adherence, and outcome in alcoholism treatment.

METHODS/DESIGN

The present study is being conducted as a randomized controlled trial. Four hundred consecutive patients aged 18 years or older will be enrolled and randomized to either self-matching or expert-matching to one of five different treatment approaches. All patients entering the alcohol outpatient clinic in Odense are offered the opportunity to participate in the study. Exclusion criteria are cognitive dysfunction as measured with the Mini Mental State Examination, and non-Danish- or non-English-speaking individuals. The following instruments will be administered at intake to provide standardized measures of alcohol problems: the Addiction Severity Index, Timeline Followback, the World Health Organization quality of life questionnaire, the NEO Five-Factor Inventory 3, and the Personal Happiness Form. For each outcome measure, two analyses will be conducted. Intention-to-treat analyses (ITT) will be carried out with all patients, regardless of whether they complete the interventions or are reinterviewed. Regarding incomplete data, multiple imputations will be used together with ITT analysis. Completer analyses will also be carried out with patients who complete their respective interventions. The primary outcome is decrease in number of monthly excessive drinking days 6 months after initiation of treatment. Secondary outcomes are compliance and 2 quality of life. The influence of personality traits on outcome will also be examined in both groups.

DISCUSSION

The debate on matching patients to treatment has been going on for decades. This study will cast light on this issue by focusing on patients' choice and thereby clarifying if patients' perceived autonomy yields better outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03278821 . Registered on 12 September 2017.

Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial

BACKGROUND

Treatment of alcohol use disorders (AUDs) is characterized by an adherence rate below 50%. Clinical research has found that patient adherence enhances treatment effect; hence, health authorities, clinicians, and researchers strive to explore initiatives contributing to patients receiving treatment. Concurrently, videoconferencing-based treatment is gaining ground within other addiction and psychiatric areas.

OBJECTIVE

The aim of this study was to test whether optional videoconferencing increases adherence to and effectiveness of AUD treatment in a randomized controlled trial (RCT). We hypothesized that the intervention would decrease premature dropout (the primary outcome), as well as increase successful treatment termination, treatment duration, and treatment outcome (secondary outcomes).

METHODS

We conducted this study in the public outpatient alcohol clinic in Odense, Denmark, between September 2012 and April 2013. It was an RCT with 2 groups: treatment as usual (TAU) and treatment as usual with add-on intervention (TAU+I). The TAU+I group had the option, from session to session, to choose to receive treatment as usual via videoconferencing. Data consisted of self-reported responses to the European version of the Addiction Severity Index (EuropASI). We collected data at baseline, at follow-up at 3, 6, and 12 months, and at discharge.

RESULTS

Among consecutive patients attending the clinic, 128 met the inclusion criteria, and 71 of them were included at baseline. For the primary outcome, after 180 days, 2 of 32 patients (6%) in the TAU+I group and 12 of 39 patients (31%) in the TAU group had dropped out prematurely. The difference is significant (P=.008). After 365 days, 8 patients (25%) in the TAU+I group and 17 patients (44%) in the TAU group had dropped out prematurely. The difference is significant (P=.02). For the secondary outcomes, significantly more patients in the TAU+I group were still attending treatment after 1 year (P=.03). We found no significant differences between the 2 groups with regard to successful treatment termination and treatment outcome.

CONCLUSIONS

The results indicate that offering patients optional videoconferencing may prevent premature dropouts from treatment and prolong treatment courses. However, the small sample size precludes conclusions regarding the effect of the intervention, which was not detectable in the patients' use of alcohol and severity of problems.

TRIAL REGISTRATION

The Regional Health Research Ethics Committee System in Denmark: S-20110052; https://komite.regionsyddanmark.dk/wm258128 (Archived by WebCite at http://www.webcitation.org/6tTL3CO6u).

Client Characteristics and Therapist Style: A Combined Analysis of Impact on Retention and Effectiveness in Outpatient Substance Abuse Treatment

AIMS

To explore the effects of client and therapist characteristics along with percentage of days abstinent before admission on retention and effectiveness of outpatient substance abuse treatment.

DESIGN

The study was implemented with naturalistic principles and prospective design. The clients (N = 327) and the therapists (N = 33) were recruited from Finnish outpatient treatment units (N = 7).

Results

The client's low readiness to change, the therapist's low directiveness and low empathy predicted short duration of treatment. Client's past substance use frequency was likewise a significant predictor of retention in treatment; clients with low percentage of days abstinent at baseline dropped out much more easily. The client's high anger and low percentage of days abstinent at baseline was found to predict low percentage of days abstinent at follow-up. Greater satisfaction with support from therapist was predicted by client's high readiness to change and lower substance use frequency at baseline.

Conclusions

Retention in treatment was predicted by both client's and therapist's characteristics, while effectiveness in outpatient substance abuse treatment was more dependent on client's characteristics and earlier substance use.

The Wearable Cardioverter Defibrillator in Nonischemic Cardiomyopathy: A US National Database Analysis

BACKGROUND

The wearable cardioverter defibrillator (WCD) is often used in patients at risk of sudden cardiac death (SCD) who are not yet candidates for an implantable cardioverter defibrillator (ICD). Newly diagnosed cardiomyopathy may be reversible, and a WCD may protect patients during the initial period of risk. We evaluate the benefit and compliance of the WCD in patients with nonischemic cardiomyopathy (NICM).

METHODS

We reviewed a national database of patients with NICM who used WCDs and who self-reported a history of excess alcohol use, although other causes of cardiomyopathy could not be excluded. The database contained demographic data, initial ejection fraction (EF), reason for WCD prescription, compliance and use data, any detected arrhythmias, therapies, and reason for discontinuing WCD. Statistical analyses were performed using SAS, version 9.3 (SAS Institute, Cary, NC).

RESULTS

Of the 127 patients, 88% were men with a mean age of 52.6 ± 11.0 years. The mean initial EF was 19.9% ± 7.4%. Patients wore the WCD for a median of 51 days and a median daily use of 18.0 hours per day. The most common reasons for discontinuing the WCD were improvement in EF (33%) or ICD implantation (23.6%). Seven patients (5.5%) had 9 sustained ventricular arrhythmia events, which were successfully treated with 100% conversion. There were 11 deaths (8.6%) during 100 days of follow-up. No deaths resulted from WCD shock failure or undersensing.

CONCLUSIONS

NICM may have a significant risk of ventricular arrhythmias and death in the first few months. The WCD delivered appropriate therapy in 5.5% of patients. This study suggests that a WCD may be effective temporary prophylaxis for prevention of SCD in patients with newly diagnosed NICM.

Therapist's Gender and Gender Roles: Impact on Attitudes toward Clients in Substance Abuse Treatment

The purpose of the present study was to investigate the impact of therapist's gender and gender roles on attitudes toward clients. Attitudes toward motivational interviewing were also a focus as MI can be hypothesized to be feminine rather than masculine in nature. The subjects (N = 246) were Finnish substance abuse therapists. Their attitudes toward clients were measured using a vignette task. Results indicated that female therapists were significantly more positive toward clients than were male therapists. Although females were significantly more feminine than males, they saw themselves as masculine as the males did. The more feminine the therapist was, the more s/he preferred MI. In the future, an examination of this kind should be combined with measurement of treatment processes and outcomes.

Opportunities for prevention of alcohol-related death in primary care: results from a population-based cross-sectional study

The mortality rate from alcohol-related conditions has risen sharply in the United Kingdom and it is not known whether opportunities for preventive interventions could be improved. The purpose of our study was to identify opportunities to detect, assess, and manage alcohol problems in primary care according to evidence-based guidelines. We carried out a cross-sectional study on patients who died from alcohol-related conditions in the calendar year 2003 within National Health Service Greater Glasgow Health Board area, Scotland (population 920,000). We described patient characteristics and care recorded in health service records, comparing it with best evidence-based practice in Scottish Intercollegiate Guidelines Network and Health Technology Board for Scotland recommendations on the management of harmful drinking and alcohol dependence. 501 deaths occurred from an alcohol-related cause. The mean age at death was 57.5 years and 72% were male. The most common causes of death, recorded by the International Classification of Diseases, revision 10, excluding accidents, were alcoholic liver disease (290, 57.9%) and mental and behavioural disorders due to alcohol (70, 14.0%). Lifetime mean consultations at primary care general practitioner and hospital outpatient departments were 24 in males and 5 in females. All individuals who died from an alcohol-related cause had at least one biochemical or physical indicator suggestive of alcohol misuse. 21% (95% CI 13-33%) had no record of having been advised to abstain from alcohol and 23% (95% CI 15-35%) had received brief interventions. 58% (95% CI 46-70%) had been referred to specialist alcohol services but a third of them did not attend. The majority of patients (83%, 95% CI 72-90%) had no evidence of shared health service and social work care. We concluded that individuals who died from alcohol-related conditions were usually in contact with statutory and voluntary services but further efforts were required to use these opportunities to detect, assess, and manage serious alcohol problems according to evidence-based guidelines.

Big five personality traits and interpersonal functioning in female and male substance abuse therapists

The purpose of the study was to investigate whether gender differences occur in personality traits or interpersonal functioning among substance abuse therapists in the same way as they do on population level. The subjects (N = 162) were therapists in Finnish inpatient treatment institutions. Female therapists (N = 119) scored significantly higher than male therapists (N = 43) on two personality factors: friendliness and openness to experiences. Women were also better than men in interpersonal functioning; they scored higher on all dimensions of it, namely, empathy, genuineness, respect for client, and concreteness.

[Referral to internal medicine for alcoholism: influence on follow-up care]

BACKGROUND AND AIMS

The problem of high rates of patient drop-out in alcohol treatment programs is frequently reported in the literature. Our aim was to investigate if internal medicine referral could improve abstinence and retention rates in a cohort of alcoholic patients.

PATIENTS AND METHODS

A retrospective observational study was conducted comparing 200 alcoholic patients attending a psychiatric unit (group 1) with 100 patients attending both this unit and an internal medicine unit (group 2). We collected sociodemographic and clinical variables and analysed differences regarding abstinence and retention rates by means of univariate and multivariate analysis.

RESULTS

At 3 and 12 months follow-up, group 2 patients had higher retention and abstinence rates than group 1 patients. Multivariate analysis including potential confounding variables showed that independent predictors of one-year retention were internal medicine referral and being married. Independent predictors of one-year abstinence were being married, age > 44 years and receipt of drug treatment.

CONCLUSIONS

The higher retention rate found among patients referred to Internal Medicine specialists, a result that has not been previously reported to the best of our knowledge, emphasizes the importance of a multidisciplinary team approach in the treatment of alcoholism.

A randomized controlled trial of Minnesota day clinic treatment of alcoholics

AIM

To compare the Minnesota day clinic treatment with the traditional public psychosocial treatment.

DESIGN

Randomized controlled trial.

SETTING

Public out-patient alcohol clinic and privately funded Minnesota day clinic in Denmark.

PARTICIPANTS

A total of 148 individuals with alcohol dependence were included in a 1-year clinical trial.

MEASUREMENTS

Self-reported drinking pattern and the seven composite scores from the addiction severity index (ASI).

FINDINGS

A total of 42 (57%) and 45 (61%) patients (P > 0.05) completed the Minnesota treatment and public treatment, respectively. Throughout the whole 12-month follow-up period, 35% of the patients treated at the Minnesota day clinic were abstainers, while this was the case for 20% of the patients treated in the public out-patient alcohol clinic (P = 0.043). During the last month before the end of the 1-year follow-up, 53% of the patients treated according to the Minnesota model were abstainers, while this was the case for 43% of the patients treated in the public out-patient alcohol clinic (P = 0.249). There were insignificant differences in the seven ASI scores.

CONCLUSIONS

Twelve months after onset of treatment, the Minnesota day clinic treatment does not differ in effect from the much cheaper 'standard' public treatment. However, patients in Minnesota treatment were total abstainers throughout a longer period.

THE EFFECTIVENESS OF A TAILORED INTERVENTION FOR EXCESSIVE ALCOHOL CONSUMPTION PRIOR TO ELECTIVE SURGERY

AIM

To assess the effectiveness of a tailored pre-operative intervention for excessive alcohol consumption in reducing post-operative complications and alcohol consumption thereafter.

METHODS

Patients scheduled for elective surgery requiring at least overnight hospitalisation were screened for alcohol misuse. Consenting, eligible participants with > or =7 days to surgery at the time of screening were offered an intervention and those with <7 days to surgery were provided usual care.

RESULTS

Over a period of 2 years and 10 months, 3139 patients were screened to recruit 136 participants. Baseline analysis revealed a mean age of 53 (+/-15.8) years and a mean consumption of 71 g/day (+/-48.1). The intervention group (n = 45) did not differ significantly from controls (n = 91) in age, consumption, and number of current smokers, but there were significantly more women in the control group. There was no difference between the groups in major or minor complications experienced, or length of stay after controlling for age, gender, and baseline consumption. At 6-month follow-up there was a significant reduction in drinking for the entire study population.

CONCLUSION

The study did not demonstrate any beneficial effect of the pre-operative intervention on post-operative complications. The relatively short time to surgery, intervention by a non-member of the surgical team, challenges to recruitment and reduced consumption in the control group may have limited the ability of the study to detect a significant effect of the intervention.

Influence of pretreatment coping strategies on the outcome of outpatient treatment of Danish alcohol abusers

An important issue regarding treatment for alcohol abuse is the high rate of relapse following treatment. In the research on treatment of alcohol abuse, the concept of coping has been proposed as a relevant factor in the relationship between relapse crises and treatment outcome. The present study investigated the role of pretreatment coping strategies in outcome of outpatient treatment for alcohol abuse. The pretreatment coping strategies of 136 clients receiving outpatient treatment for alcohol abuse were examined as a predictor of drinking pattern after treatment. The pretreatment coping strategies were assessed by the COPE questionnaire. Drinking pattern after treatment was assessed at follow-up one year after treatment was entered. Results indicated that some pretreatment coping strategies are identifiable as adaptive and maladaptive coping strategies, respectively, regarding successful treatment for alcohol abuse. Restraint coping was found predictive of a positive drinking pattern at follow-up while the use of alcohol to cope was found predictive of a negative drinking pattern. Furthermore, the results showed tendencies towards the possibility that some coping strategies co-operated differently with types of treatment methods.

Therapist rotation--a new element in the outpatient treatment of alcoholism

For nine years, the so-called "therapist rotation" has been a central part of OLITA, the Outpatient Longterm Intensive Therapy for Alcoholics. Thus far, the participation of several equally responsible therapists in the treatment of a patient has rarely been seen as a specific therapeutic approach. The present article analyzes the therapist rotation from a theoretical and clinical perspective. Articles concerned with the therapeutic alliance in the treatment of substance use disorders are reviewed. Furthermore, the literature on multiple psychotherapy, which may be seen as the precedent of the therapist rotation is surveyed. Based on the efficacy of multiple psychotherapy and the importance of the therapeutic alliance in the treatment of substance use disorders, the present work discusses the therapist rotation as an essential factor for the success of OLITA. It considers both potential advantages and disadvantages for patients and therapists and tries to identify conditions under which this approach appears to promote therapeutic interactions. Finally, the implementation of therapist rotation into OLITA is described, including the theoretical background of the program itself and the treatment procedure. New areas of application for the therapist rotation are discussed.

The therapists' experience of alcohol addiction treatment – a qualitative study

The present study is a qualitative study, based on audio-taped interviews with 12 therapists, on how therapists view their own role as therapists within the alcohol treatment areas.

The study describes how the therapists create an image of the patients they treat, and the rationale, they build the treatment on. The analysis of the therapists' stories indicated that therapists based their treatment on a platform that was constructed and negotiated by means of various kinds of information and knowledge. From this stock of information the therapists pulled out and interpreted elements that made coherent sense to them and provided indications about where to go next in the course of treatment.

The stories about treatment were told within the frames of a recognisable structure, consisting of the patient's predisposition to treatment, empowerment, transformation and re-construction. Within this structure, the therapists rhetorically made use of various patterns to describe their communication with the patients. The rhetoric can be regarded as an indication of how the therapists perceive their role as therapist.

As the therapist viewed it, treatment was aimed at helping the patient overcome dependence and at the same time letting the patient be the active decision-maker. The stories about treatment showed how the therapist viewed treatment as an act of balancing between dependence and independence.

Alcohol problems and treatment: the patients' perceptions

The aim of this study is to investigate the patients' perception of their own alcohol problems. It is based on semi-structured, audio-taped interviews with 27 randomly chosen patients at an Alcohol Treatment Centre. Four different ways how alcohol problems were perceived emerged: 'cultural drinking', 'symptomatic drinking', 'pathological drinking' and 'incomprehensible drinking'. The ways of explaining the drinking problems were not related to the duration of the drinking problem, the actual amount of alcohol that the patients drank, or how or when it was drunk. Instead, the patients' perceptions were grounded in the way the drinking pattern was interpreted in relation to concepts like 'normality' and 'deviance'.